Maternal Safety Bundle for
Severe Hypertension in Pregnancy
Disclaimer: The following material is an example only and not meant to be prescriptive. ACOG
accepts no liability for the content or for the consequences of any actions taken on the basis
of the information provided.
EXAMPLE
Maternal Mortality
P REGNANCY -R ELATED M ORTALITY IN THE U.S.
(1987 – 2013)
Maternal Mortality
NYS Three-Year Rolling Average Maternal Mortality Rate
*Causes of death from death records A34, O00-O95,O98-O99.
2000-2014 data from NY Vital Records. 2015 NY and national data from CDC Wonder database.
Maternal Mortality
What’s causing these deaths?
• NYS maternal mortality review (MMR) identified 62 pregnancy-related & 104 pregnancy-associated, not related deaths, from 2012-13.
• Leading causes of pregnancy-related deaths:
• Embolism (29%)
• Hemorrhage (17.7%)
• Infection (14.5%)
• Cardiomyopathy (11.3%)
• Leading causes of pregnancy-associated deaths:
• Injury (51.9%)
• Cancer (8.7%)
• Generalized septicemia (5.8%)
• Cardiac arrhythmia (4.8%)
Maternal Mortality
P REGNANCY -R ELATED M ORTALITY IN N EW Y ORK S TATE
(2012 – 2013)
Safe Motherhood Initiative: History
• Began in 2001 as a voluntary review program to examine reported cases of hospital-based maternal deaths
• Collaborative effort between ACOG & NYSDOH
• Assisted hospitals in making protocol changes to improve patient safety and raise awareness of risk factors that can contribute to serious morbidity
• Timely recognition and intervention could have prevented many of the deaths reviewed
• De-funded in Executive Budget proposal in 2010
Safe Motherhood Initiative: History
• V2.0 kicked off in May 2013
• Develop standard approaches for managing obstetric emergencies associated with
maternal mortality and morbidity
• Focuses on the leading causes of maternal death – obstetric hemorrhage (severe
bleeding), venous thromboembolism (blood clots), severe hypertension in pregnancy (high blood pressure), maternal sepsis
• 117 obstetric hospitals engaged
• On-site implementation visits to assist with
QI efforts
Safe Motherhood Initiative: Bundles
O BSTETRIC B UNDLE D EVELOPMENT :
Founded in evidence-based, best practices
• Delineation of standard of care
• Minimization of variability
• Decreased reliance on memory
• Emphasized patient safety
• Reduction in redundant
efforts
Safe Motherhood Initiative: Bundles
O BSTETRIC B UNDLE C OMPOSITION :
Tangible tools hospitals can use to implement directives
• PowerPoint slide decks
• Visual aids posters
• Checklists
• Algorithms
• Risk assessment tables
• Medication dosing tables
• Debriefing forms
RISK ASSESSMENT & PREVENTION
• Diagnostic Criteria
• When to Treat
• Agents to Use
• Monitoring
READINESS & RESPONSE
• Complications & Escalation Process
• Further Evaluation
• Change of Status
• Postpartum Surveillance
KEY ELEMENTS : HTN BUNDLE
EXAMPLE
Types of Hypertension
Chronic Hypertension
o SBP ≥ 140 or DBP ≥ 90 o Pre-pregnancy or <20 weeksGestational Hypertension
o SBP ≥ 140 or DBP ≥ 90 on at least two occasions at least 4 hrs apart after 20 weeks gestation in women with previously normal BP
o Absence of proteinuria or systemic signs/symptoms
Preeclampsia – Eclampsia
o SBP ≥ 140 or DBP ≥ 90
o Proteinuria with or without signs/symptoms
o Presentation of signs/symptoms/lab abnormalities but no proteinuria
*Proteinuria not required for diagnosis eclampsia seizure in setting of preeclampsia
Chronic Hypertension with Superimposed Preeclampsia
o Preeclampsia in a woman with a history of hypertension before pregnancy or before 20 weeks of gestation
Preeclampsia
with severe features
(ACOG Practice Bulletin #202, Gestational Hypertension and Preeclampsia, & ACOG Practice Bulletin #203, Chronic
Hypertension in Pregnancy)
o SBP ≥ 160 or DBP ≥ 110 (can be confirmed within a short interval to facilitate timely antihypertensive therapy)
o Thrombocytopenia (platelet count less than 100,000/microliter)
o Impaired liver function that is not accounted for by alternative diagnoses and as indicated by abnormally elevated blood concentrations of liver enzymes (to more than twice the upper limit normal concentrations), or by severe persistent right upper quadrant or epigastric pain
unresponsive to medications.
o Renal insufficiency (serum creatinine concentration more than 1.1 mg/dL or a doubling of the serum creatinine concentration in the absence of other renal disease)
o Pulmonary edema
EXAMPLE
Definitions
SEVERE HYPERTENSION
• Systolic blood pressure ≥ 160 mm Hg and/or
• Diastolic blood pressure ≥ 110 mm Hg
• Measured on two occasions at least 4 hours apart
HYPERTENSIVE EMERGENCY
• Persistent, severe hypertension that can occur antepartum, intrapartum, or postpartum
• Defined as:
- Two severe BP values (≥ 160/110) taken 15-60 minutes apart - Severe values do not need to be consecutive
EXAMPLE
When to Treat
SEVERE HYPERTENSION
• SBP ≥ 160 or DBP ≥ 110
HYPERTENSIVE EMERGENCY
• Persistent, severe hypertension that can occur antepartum, intrapartum, or postpartum
• Two severe BP values (≥ 160/110) taken 15-60 minutes apart
• Severe values do not need to be consecutive
o Repeat BP every 5 min for 15 min
o Notify physician after one severe BP value is obtained
o If severe BP elevations persist for 15 min or more, begin treatment ASAP. Preferably within 60 min of the second elevated value.
o If two severe BPs are obtained within 15 min, treatment may be initiated if clinically indicated
EXAMPLE
First Line Therapies
• Intravenous labetalol
• Intravenous hydralazine
• Oral nifedipine
Magnesium sulfate not recommended as antihypertensive agent
Should be used for: seizure prophylaxis and controlling seizures in eclampsia
IV bolus of 4-6 grams in 100 ml over 20 minutes, followed by IV infusion of 1-2 grams per hour. Continue for 24 hours postpartum
If no IV access, 10 grams of 50% solution IM (5 g in each buttock)
Contraindications: pulmonary edema, renal failure, myasthenia gravis
Anticonvulsants (for recurrent seizures or when magnesium is C/I):
• Lorazepam: 2-4 mg IV x 1, may repeat x 1 after 10-15 min
• Diazepam: 5-10 mg IV every 5-10 min to max dose 30 mg
• Phenytoin: 15-20 mg/kg IV x 1, may repeat 10 mg/kg IV after 20 min if no response. Avoid with hypotension, may cause cardiac arrhythmias.
• Keppra: 500 mg IV or orally, may repeat in 12 hours. Dose adjustment needed if renal impairment .
EXAMPLE
EXAMPLE
10
EXAMPLE
11
EXAMPLE
12
Additional Therapy Recommendations
IF NO IV ACCESS AVAILABLE :
• Initiate algorithm for oral nifedipine, or
• Oral labetalol, 200 mg * Repeat in 30 min if SBP remains ≥ 160 or DBP ≥ 110 and IV access still unavailable
SECOND LINE THERAPIES (if patient fails to respond to first line tx):
Recommend emergency consult with:
• Maternal Fetal Medicine
• Internal Medicine
• Anesthesiology
• Critical Care
• Emergency Medicine
May also consider:
Labetalol or nicardipine via infusion pump
EXAMPLE
Monitoring Blood Pressure
MATERNAL FETAL
• Once BP is controlled (<160/110), measure
Every 10 minutes for 1 hour
Every 15 minutes for next hour
Every 30 minutes for next hour
Every hour for 4 hours
• Obtain baseline labs:
CBC
Platelets
LDH
Liver Function Tests
Electrolytes
BUN creatinine
Urine protein
• Fetal monitoring surveillance as appropriate for gestational age
EXAMPLE
Call for assistance
Designate team leader, checklist reader, primary RN
Ensure side rails are up
Administer seizure prophylaxis
Antihypertensive therapy within 1 hr for persistent severe range BP
Place IV; Draw PEC labs
Antenatal corticosteroids is <34 wks gestation
Re-address VTE prophylaxis requirement
Place indwelling urinary catheter
Brain imaging if unremitting headache or neurological symptoms
EXAMPLE
Call for assistance
Designate team leader, checklist reader, primary RN
Ensure side rails are up
Protect airway + improve oxygenation
Continuous fetal monitoring
Place IV; Draw PEC labs
Administer antihypertensive therapy if appropriate
Develop delivery plan
Debrief patient, family, OB team
EXAMPLE
Complications & Escalation Process
MATERNAL (pregnant or postpartum) FETAL
• CNS (seizure, unremitting headache, visual disturbance)
• Pulmonary edema or cyanosis
• Epigastric or right upper quadrant pain
• Impaired liver function
• Thrombocytopenia
• Hemolysis
• Coagulopathy
• Oliguria *<30 ml/hr for 2 consecutive hours
• Abnormal fetal tracing
• IUGR
Prompt evaluation and communication: If undelivered, plan for delivery
EXAMPLE
Monitoring Change of Status
Once patient is stabilized, consider :
SEIZURE PROPHYLAXIS
o Magnesium sulfate (if not already initiated )
TIMING & ROUTE OF DELIVERY
o Eclampsia Delivery after stabilization o HELLP/Severe preeclampsia/
Chronic hypertension + superimposed
preeclampsia Vaginal delivery, if attainable in reasonable amount of time
o ≥ 34 weeks Deliver
MATERNAL BP
o Continue control with oral agents o Target range of 140-150/90-100
IF PRETERM (<34 WKS) & EXPECTANT MGMT PLANNED o Antenatal corticosteroids
o Subsequent pharmacotherapy
o HELLP (Gestational age of fetal viability to 33 6/7 wks)
Delay delivery for 24-48 hours if maternal and fetal condition remains stable
Contraindications to delay in delivery for fetal benefit of corticosteroids:
• Uncontrolled hypertension
• Eclampsia
• Pulmonary edema
• Suspected abruption placenta
• Disseminated intravascular coagulation,
• Nonreassuring fetal status
EXAMPLE
ON ADMISSION ASSESSMENT & PLAN
Complete history
Complete physical exam + preeclampsia symptoms:
o Unremitting headaches o Visual changes
o Epigastric pain o Fetal activity o Vaginal bleeding
Baseline BPs throughout pregnancy
Meds/drugs throughout pregnancy (illicit & OTC)
Current vital signs, inc. O2 saturation
Current and past fetal assessment:
o FHR monitoring results o Est. fetal weight
Indicate diagnosis of preeclampsia
o If no dx, indicate steps taken to exclude preeclampsia
Antihypertensives taken ( if any) o Specific medications
o Dose, route, frequency o Current fetal status
Magnesium sulfate (if initiated for seizure prophylaxis)
o Dose, route, duration of therapy
Delivery assessment
o If indicated, note: timing, method, route o If not indicated, describe circumstances to
warrant delivery
Antenatal corticosteroids if < 34 weeks of
Guidelines for Documentation
EXAMPLE
Postpartum Surveillance
Necessary to prevent additional morbidity as preeclampsia/eclampsia can develop postpartum
INPATIENT OUTPATIENT
• Measure BP every 4 hours after delivery until stable
• Do not use NSAIDs for women with elevated BP
• Do not discharge patient until BP is well controlled for at least 24 hours
• For pts with preeclampsia, visiting nurse evaluation recommended:
Within 3-5 days
Again in 7-10 days after delivery (earlier if persistent symptoms)
ANTIHYPERTENSIVE THERAPY
• Recommended for persistent postpartum HTN: SBP ≥ 150 or DBP ≥ 100 on at least two occasions at least 4 hours apart
• Persistent SBP ≥ 160 or DBP ≥ 110 should be treated within 1 hour
EXAMPLE
Call for assistance
Designate team leader, checklist reader, primary RN
Ensure side rails up
Call OB consult; Document call
Place IV; Draw PEC labs
Administer seizure prophylaxis
Administer antihypertensive therapy
Consider indwelling urinary catheter. Maintain strict I&O
Brain imaging if unremitting headache or neurological symptoms
EXAMPLE
Discharge Planning
All patients receive information on preeclampsia:
Signs and symptoms
Importance of reporting information to health care provider as soon as possible
Culturally-competent, patient-friendly language
All new nursing and physician staff receive information on hypertension in pregnancy and postpartum
FOR PATIENTS WITH PREECLAMPSIA
BP monitoring recommended 72 hours after delivery
Outpatient surveillance (visiting nurse evaluation) recommended:
o Within 3-5 days
o Again in 7-10 days after delivery (earlier if persistent symptoms)
EXAMPLE
Post-Discharge Evaluation
ELEVATED BP AT HOME , OFFICE , TRIAGE
Postpartum triggers:
• SBP ≥ 160 or DBP ≥ 110 or
• SBP ≥ 140-159 or DBP ≥ 90-109 with unremitting headaches, visual disturbances, or epigastric/RUQ pain
• Emergency Department treatment (OB /MICU consult as needed)
• AntiHTN therapy suggested if persistent SBP > 150 or DBP > 100 on at least two occasions at least 4 hours apart
• Persistent SBP > 160 or DBP > 110 should be treated within 1 hour
Good response to antiHTN treatment and asymptomatic
Signs and symptoms of eclampsia, abnormal neurological evaluation, congestive heart failure, renal failure, coagulopathy, poor response to antihypertensive treatment Admit for further observation and
management
(L&D, ICU, unit with telemetry )
Recommend emergency consultation for further evaluation (MFM, internal medicine, OB anesthesiology, critical care)
EXAMPLE
Conclusion
Systolic BP ≥ 160 or diastolic BP ≥ 110 warrant:
Prompt evaluation at bedside
Treatment to decrease maternal morbidity and mortality
Risk reduction and successful clinical outcomes require avoidance/management of severe systolic and diastolic hypertension in women with:
Preeclampsia
Eclampsia
Chronic hypertension + superimposed preeclampsia
Increasing evidence indicates that standardization of care improves patient outcomes
EXAMPLE
• Abalos E, Duley L, Steyn DW, Henderson-Smart DJ. “Antihypertensive drug therapy for mild to moderate hypertension during pregnancy (review).”
The Cochrane Collaboration. 2007, Issue 1. Art. No.: CD002252. DOI: 10.1002/14651858.CD002252.pub2.
• Chronic hypertension in pregnancy. ACOG Practice Bulletin No. 203. American College of Obstetricians and Gynecologists. Obstet Gynecol 2019;133:e26–50.
• Churchill D, Duley L. “Interventionist versus expectant care for severe pre-eclampsia before term.” The Cochrane Collaboration. 2002, Issue 3. Art.
No.: CD003106. DOI: 10.1002/14651858.CD003106.
• Creanga, A. A., Syverson, C., Seed, K., & Callaghan, W. M. (2017). Pregnancy-Related Mortality in the United States, 2011-2013. Obstetrics and gynecology, 130(2), 366–373. doi:10.1097/AOG.0000000000002114
• Duley L, Gülmezoglu AM, Henderson-Smart DJ. “Magnesium sulphate and other anticonvulsants for women with preeclampsia (review).” The Cochrane Collaboration. 2003, Issue 2. Art. No.: CD000025. DOI: 10.1002/14651858.CD000025.
• Duley L, Henderson-Smart DJ, Meher S. “Drugs for treatment of very high blood pressure during pregnancy (review).” The Cochrane Collaboration.
2006, Issue 3. Art. No.: CD001449. DOI: 10.1002/14651858. CD001449.pub2.
• Emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum period. ACOG Committee Opinion No. 767. American College of Obstetricians and Gynecologists. Obstet Gynecol 2019;133:e174–80.
• Gestational hypertension and preeclampsia. ACOG Practice Bulletin No. 202. American College of Obstetricians and Gynecologists. Obstet Gynecol 2019;133:e1-25.
• Maurice L. Druzin, MD; Laurence E. Shields, MD; Nancy L. Peterson, RNC, PNNP, MSN; Valerie Cape, BSBA. “Preeclampsia Toolkit: Improving Health Care Response to Preeclampsia.” California Maternal Quality Care Collaborative Toolkit to Transform Maternity Care. Developed under contract
#11-10006 with the California Department of Public Health; Maternal, Child and Adolescent Health Division; Published by the California Maternal Quality Care Collaborative, November 2013.
• National Institute for Health and Clinical Excellence. “The management of hypertensive disorders during pregnancy.” NICE Clinical Guideline #107.
Modified January 2011.
• New York State Department of Health. “Hypertensive Disorders in Pregnancy.” NYSDOH Executive - Guideline Summary, May 2013.
• New York State Maternal Mortality Review Report, 2017. Retrieved from
https://www.health.ny.gov/community/adults/women/docs/maternal_mortality_review_2012-2013.pdf
• Shekhar et al. “Oral Nifedipine or Intravenous Labetalol for Hypertensive Emergency in Pregnancy.” Obstetrics and Gynecology, 2012 (122):
1057-1063.
References
Safe Motherhood Initiative
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